Quote from comalley
Thank you for taking the time to reply. I have not explaned myself corectly. Instead of doing my pt. assessment then concluding what my pt. acutual problem is and doing a care plan from that my teacher wants me to take the medical dx. and decide what top 4 nursing assessments i would do for that pt. upon entering the room. That being said the report given was that my pt. had just returned from a CT guided needle bx of the neck for neck pain and an area of concern on an MRI. The orders were neuro checks q4h, dressing checks, pain meds q4h, and bedrest. So the top 4 assessments when i walk into the room was 1-pain 2-neuro 3-skin/dressing and 4-musculoskeletal. now i need a nursing dx for each assessment.
pain for pain,
risk for injury neurological r/t invasive cervical procedure for neuro
I went with impaired skin integrity r/t incision for diagnostic procedure and temp restrictions on mobility for skin/dressing
imapired mobility r/t pain and h/o joint repair surgery for musculoskeletal
Nanda did not have a proper fitting dx for the neuro assessment again because I am sure that doing a care plan this way is incorrect. So I need to know if what I put together is fitting for what she wants.
BTW the pt. real problem was 1-pain 2-decreased mobility from pain 3-constipation 4-distress about driving a car upon discharge (lives alone 85yo)
Sure the is a diagnosis for neuro......what are you looking for with the neuro check.....a change in sensory perception. numbness, decreased sensation, hypersensitivity, weakness..right?
NANDA I.........Disturbed Sensory perception (specify: visual, auditory, kinesthetic, gustatory, tactile, olfactory)RT the procedure.
Change in behavior pattern; change in problem-solving abilities; change in sensory acuity
; change in usual response to stimuli;
disorientation; hallucinations; impaired communication; irritability; poor concentration; restlessness; sensory distortions
Related Factors (r/t)
Altered sensory integration
; altered sensory reception; altered sensory transmission
; biochemical imbalance; electrolyte imbalance; excessive environmental stimuli; insufficient environmental stimuli; psychological stress